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["別紙第７"]
[]
["国 家 公 務 員 災 害 補 償"]
["葬　祭　補　償　請　求　書"]
[]
["（実施機関の長の官職氏名）",{"$nulls":12},"請求年月日",{"$nulls":5},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":13},"請求者の住所　　 　　　　　　　　　　　　　　　　"]
[{"$nulls":12},"殿"]
[]
["下記の葬祭補償を請求します。",{"$nulls":12},"氏名"]
[]
[{"$nulls":13},"職員との続柄\n又は関係"]
[]
[]
[" １\n\n 死亡職員\n\n に関する\n\n 事項",null,null,"（所属部局）",{"$nulls":9},"（氏　名）"]
[]
[{"$nulls":22},"年",null,"月",null,"日生"]
[]
[null,null,null,"（官職）",{"$nulls":9},"（死亡年月日）"]
[{"$nulls":4},"□","常　勤"]
[{"$nulls":4},"□","非常勤",{"$nulls":13},"令和",null,null,"年",null,"月",null,"日"]
[]
["２　葬祭補償請求金額",{"$nulls":5},"（Ａ）",null,"規則16-0第31条第１項\nに規定する定額",{"$nulls":5},"（平均給与額）"]
[]
[{"$nulls":13},"円","＋",{"$nulls":4},"円×30＝",{"$nulls":6},"円"]
[{"$nulls":6},"（Ｂ）",{"$nulls":7},"（平均給与額）"]
[{"$nulls":19},"円×60＝",{"$nulls":6},"円"]
[{"$nulls":6},"（Ａ）（Ｂ）のうち\n高い方の金額"]
[{"$nulls":13},"□","（Ａ）",null,"□","（Ｂ）",{"$nulls":8},"円"]
[]
["※受理",{"$nulls":6},"※決定",{"$nulls":6},"※支払",{"$nulls":6},"※決定金額"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",{"$nulls":5},"円"]
["　注　１　請求者は、※印の欄には記入しないこと。該当する□にレ印を記入すること。"]
["　　　２　この請求書には、平均給与額算定書を添付すること。"]